The nurse is administering cleansing enemas to a client the night before bowel surgery. During instillation of the enema, the client reports cramping and pain. What action should the nurse take?
A)Have the client take slow, deep breaths
B)Stop infusing the solution for 30 seconds, then resume at a slower rate
C)Tell the client that the process will not take much longer
D)Withdraw the tube approximately 2 cm and continue the infusion

Question

The nurse is administering cleansing enemas to a client the night before bowel surgery.  During instillation of the enema, the client reports cramping and pain.  What action should the nurse take?
A)Have the client take slow, deep breaths
B)Stop infusing the solution for 30 seconds, then resume at a slower rate
C)Tell the client that the process will not take much longer
D)Withdraw the tube approximately 2 cm and continue the infusion

Quizplus · Accepted Answer

Too rapid infusion of an enema solution may cause intestinal spasms that result in a feeling of fullness, cramping, and pain. If the client reports any of these symptoms, instillation should be stopped for 30 seconds and then resumed at a slower rate. Slow infusion will also decrease the likelihood of premature ejection of the solution, which would not allow for adequate bowel evacuation. (Option A) Having the client take slow, deep breaths may be helpful, but the infusion should be stopped first. (Option C) This response disregards the client's cramping and pain and is not appropriate. (Option D) Withdrawing the tube will risk not instilling the fluid high enough into the rectum/colon to be effective. Educational objective: If a client reports cramping or pain during instillation of an enema, the infusion should be stopped for 30 seconds and then resumed at a slower rate.

The Nurse Is Administering Cleansing Enemas to a Client the Night